CARDIOLOGY (I) OBJECTIVES 1 To provide a broad training and in-depth experience at a level sufficient for trainees to acquire competence and professionalism required of a specialist in Cardiology. 2 To enable trainees to make accurate clinical bedside diagnoses, appropriate ordering of decisive investigations, to be sensitive to unique features of individual patients and to integrate all data into a well organised management strategy. 3 To develop in the trainees the humanistic, moral and ethical aspects of medicine. 4 To foster the appreciation of cost-effectiveness of various investigational, therapeutic and preventive aspects of intervention. 5 To provide further experience in critical thinking by active participation in research. These objectives in philosophy, knowledge, skills and experience are essential to provide a solid foundation in Clinical Cardiology before advancing to focus on more subspecialised areas. 6 To acquire professional competence in training future trainees in Cardiology. (II) STRUCTURE 1. This period consists of three years of supervised and accredited training in Cardiology. The three-year training programme comprises TWO years of core training in Cardiology as described below, with a minimum of 12 months of core training to be undertaken in training units accredited by the College, plus ONE year of training in any of the following: 1.1 The same specialty which may be accredited for a maximum of 12 months, AND/OR 1.2 A broad-based specialty, defined as either Advanced Internal Medicine (AIM) or Geriatric Medicine, which may be accredited for a maximum of 12 months, AND/OR 1.3 Overseas training in Cardiology, which may be accredited for a maximum of six months, with prior approval by the specialty board, AND/ OR 1.4 Research in Cardiology, which may be accredited for a maximum of 1
six months, with prior approval by the specialty board. 2 To ensure the acquisition of a broad-based physician training for all Higher Physician Trainees undergoing Cardiology training, the College requires that all registered Higher Physician Trainees undergo dual training in a broad-based specialty, defined as either Advanced Internal Medicine (AIM) or Geriatric Medicine, together with training in Cardiology. Fellows who have been trained in Cardiology without a broad-based specialty will not be accepted as Trainer in any specialty in the future. 3 The structures of dual training programmes approved by the College include the following and Trainees must clearly indicate the programme chosen at the time of application to be registered as Higher Physician Trainee of the College: 3.1 Concurrent training: A minimum of four years of supervised training is required. The training programme comprises 24 months (cumulative) of core training in a broad-based specialty and 24 months (cumulative) of core training in Cardiology. 3.2 Sequential training: A minimum of five years of supervised training is required. The training programme comprises 36 months training in either Cardiology or the broad-based specialty followed by 24 months of core training in remaining specialty. (III) CONTENTS 1. The 2-year core training in Cardiology consists of two components Clinical Cardiology and training in special diagnostic and therapeutic skills. Clinical Cardiology training consists of two years full-time experience under supervision in one or more accredited hospitals, of which six months must be in a hospital with 24-hour general accident and emergency service. Full-time training in rehabilitation related to cardiovascular medicine may be accredited up to a maximum of six months. Training in special diagnostic and therapeutic skills are to be taken concurrently with Clinical Cardiology training and are described as follows: Coronary Care Unit 6-12 months Pre- and Post-Cardiovascular Surgery Patient Care Non-invasive Cardiology 1-3 months 2 or more sessions per week on average during the 2-year core training period Invasive Cardiology (performed in Cardiac Catheterization Laboratory, Operation Theatre or Angio suite facilities shared with Radiology Department) 1 or more sessions per week on average during the 2-year core training period. 2
(Remarks: 1 session means 1 half-day session) Trainees are required to perform minimum numbers of some procedures during the 2-year core training in Cardiology. The aim is to ensure adequate exposure to clinical material and pathology and to provide trainers sufficient opportunity to assess competency in these areas. Ambulatory ECG monitoring interpret at least 100 Exercise testing perform and interpret at least 50 Echocardiography (M-mode, 2D, Doppler) perform and interpret at least 100 Cardiac catheterization participate in at least 100 diagnostic cardiac catheterization procedures e.g. coronary angiogram, haemodynamic assessment Arrhythmia management and cardiac pacing (2) Knowledge 2.1 Training in Patient Care and Management perform at least 5 temporary pacemakers and participate in at least 20 cardiovascular implantable electronic devices (CIED) implantations 2.1.1 Skill in obtaining a comprehensive history and performing complete cardiovascular examination. 2.1.2 Familiarity with the role of psychological factors in the genesis of symptoms, and the emotional and physical response of patients to cardiovascular diseases. 2.1.3 Familiarity with the preventive and rehabilitative aspects of managing hospital patients with established or potential cardiovascular disease. 2.1.4 Experienced in addressing consultations from other physicians and non-physician specialties. 2.1.5 Direct patient care responsibility in Cardiology under the supervision of accredited trainer(s). 2.2 Training in the Understanding, Diagnosis, Prevention and Treatment of Cardiovascular Diseases 3
The trainee must be well-educated in the Pathogenesis and pathology Risk factors Natural history Diagnosis by history, physical examination and laboratory methods Medical management and principles of surgical management Complications Prevention Rehabilitation of cardiovascular conditions, including Coronary artery disease Hypertension Valvular heart disease Congenital and structural heart disease Cardiac arrhythmias Cardiomyopathy Involvement of cardiovascular system by systemic diseases Infective endocarditis Diseases of the great vessels and peripheral blood vessels Diseases of pericardium Pulmonary heart disease Cardiovascular complications of chronic renal failure Traumatic heart disease Cardiac tumours 2.3 Training in Coronary and Critical Cardiac Care At least six months of supervised working experience with patients undergoing acute coronary care and critical care of other acute cardiovascular disorders. 2.4 Training in Follow-up Care Continued responsibility for cardiovascular outpatient management and consultation. 2.4.1 Each trainee should attend to outpatients with cardiac problems at no fewer than two sessions per week for the entire core training period, or an equivalent period to be approved by the Board. 4
2.4.2 Experience with longitudinal follow-up of patients is desirable. 2.4.3 Exposure to a wide age span of patients ranging from adolescence through old age. 2.4.4 Exposure to a variety of cardiovascular cases including hypertension, lipid disorder, cardiac arrhythmias, cardiovascular implantable electronic devices (CIEDs) follow-up, post myocardial infarction, post-surgical followup, anticoagulation, post-percutaneous coronary intervention, valvuloplasty etc. 2.5 Training in Electrocardiography Skill in the performance and interpretation of Surface Electrocardiography Ambulatory Electrocardiography Exercise electrocardiographic tests 2.6 Training in Cardiac Catheterization Laboratory and Cardiac Intervention: A fully-equipped and staffed angiographic and haemodynamic laboratory dedicated to cardiac procedures is required. 2.6.1 Direct experience under supervision in an adult cardiac catheterization laboratory which performs 2.6.1.1 Right and left heart catheterizations and haemodynamic studies. 2.6.1.2 Ventriculography and angiography including coronary and major vessels arising from the aorta. 2.6.1.3 Cardiac interventional procedures e.g. percutaneous coronary intervention, temporary right ventricular pacing, pericardiocentesis, myocardial biopsy, intraaortic balloon counterpulsation. 2.6.2 Development of a sound knowledge of the fundamentals of cardiovascular physiology as related to clinical disease, analysis of haemodynamic records and interpretation of angiographic images. 5
2.6.3 Development of a sound knowledge of the principles of radiation safety. 2.6.4 Cardiovascular surgery must be performed in, or be readily accessible to, the institution to which the accredited training unit belongs. 2.7 Training in Echocardiography 2.7.1 Participation in the performance of echocardiography including M-Mode and 2D-echocardiography Doppler echocardiography Colour flow imaging Transoesophageal echocardiography Exercise and pharmacological stress echocardiography (preferable). 2.7.2 Development of a sound knowledge in the fundamental principles of ultrasound imaging, analysis and interpretation of echocardiographic records in relation to clinical disease. 2.8 Training in Diagnostic Radiology and Nuclear Medicine Development of a sound knowledge of the principles, indications and limitations of nuclear cardiovascular procedures and magnetic resonance imaging (MRI) studies and computed tomography imaging. 2.9 Training in Cardiovascular Implantable Electronic Devices (CIEDs) 2.9.1 Development of a sound knowledge of the principles and limitations of, and indications for, cardiac pacemakers, implantable cardioverter defibrillators, cardiac resynchronization therapy, cardiac resynchronization therapy defibrillator, implantable loop recorder. 2.9.2 Direct experience under supervision in the implantation of single and dual chambers permanent cardiac pacemakers. 2.9.3 Development of a sound knowledge of the principles of management of patients with CIEDs, trouble-shooting when complications occur, and optimal programming of CIEDs in accordance with patients physiological and pathological conditions. 6
2.10 Training in Electrophysiology and Catheter Ablation 2.10.1 Development of a sound knowledge of the indications for, limitations of and skill in, the selection of patients for electrophysiology studies and catheter ablation. 2.10.2 The trainee should be well-educated in the principles of electrophysiology studies and catheter ablation in relations to the manifestations of clinical diseases and patient management. 2.11 Training in Peripheral Vascular Disease 2.11.1 Development of a sound knowledge of the clinical features and treatment of peripheral vascular disease. 2.11.2 Competence in the history and physical examination of patients suffering from diseases of the arterial and venous systems. 2.11.3 Education in selecting and interpreting peripheral angiography, and other imaging and Doppler vascular studies. 2.12 Training in Cardiovascular Research All trainees should participate actively in research activities. 2.13 Training in Related Sciences 2.13.1 Understanding of the normal physiology of the circulatory system, including adaptation of the cardiovascular system to exercise, stress, pregnancy, ageing, as well as renal and pulmonary abnormalities. 2.13.2 Continuing education in basic sciences including the aspects of anatomy, physiology, pharmacology, pathology, biophysics and biochemistry that are pertinent to Cardiology. 2.13.3 Experience with programmes in computer sciences and biostatistics is desirable. 2.14 Training in Related Fields of Medicine 7
2.14.1 Radiology: The interpretation of cardiovascular images. 2.14.2 Surgery: The risks and benefits of cardiovascular surgery, and the rationale for selection of candidates for surgical treatment. Participation in pre- and post-operative care. 2.14.3 Anaesthesia: Close collaboration with anaesthesia colleagues in the pre- and post-operative management of patients with cardiac disease. 2.14.4 Pulmonary: Solid knowledge of basic pulmonary disease physiology. Interpretation of pulmonary function testing, blood gases, pulmonary angiography and radioactive lung scanning. Experience in the management of acute pulmonary problems. 2.14.5 Obstetrics: Experience in the clinical management of pregnant patients with heart disease. 2.14.6 Physiology: Physiology of the cardiovascular system, its response to exercise and stress, and its alterations produced by disease. 2.14.7 Pharmacology: The pharmacology and interactions among cardiovascular as well as other drugs. 2.14.8 Pathology: Familiarity with the gross and microscopic pathology of all major forms of heart disease. 2.14.9 Procedural sedation: Knowledge and skills of procedural sedation pharmacology of sedation medications and reversal agents, indications and contraindications, assessment and monitoring, management of complications and emergency. (3) Specialty Clinical Skills Advanced cardiac interventional procedures require additional postfellowship training. Further training for one year post-core Cardiology accreditation in one or more special procedures is desirable but not mandatory. e.g. (a) Percutaneous coronary intervention. (b) Electrophysiology studies and catheter ablation. (c) Structural heart intervention. (4) Attitudes 8
Enhance and re-inforce the attitudes inculcated during basic physician training. (IV) INSTITUTIONAL REQUIREMENTS 1 Core training in Cardiology aims to provide comprehensive exposure to various fields of Cardiology practice, exchange of experience and facilitation of peer discussion, review and audit. 1.1 The training unit should therefore have a comprehensive range of training activities and spectrum of in-patients and out-patients with a variety of cardiac problems. 1.2 Sufficient number of accredited trainers for training in Clinical Cardiology. 1.3 Adequate facilities for the management of all common cardiac conditions and emergencies. 2 Centres providing core training in Cardiology may be regularly assessed and accredited by the Specialty Board according to 2.1 Facilities and equipments. 2.2 Scope and volume of activities in the programme. 2.3 Experience of trainers in the relevant subspecialty field. 3 Each trainee should be under supervision of more than one trainer in Cardiology and the minimum trainer: trainee ratio should not be less than 1:2. 4 In the assessment of training units/programmes, the Specialty Board in Cardiology will also consider the availability of and participation in interhospital/interdepartmental conferences, meetings and lectures as well as networking activities. 9